CENTRAL LUZON DOCTORS’ HOSPITALEDUCATIONAL INSTITUTION

San Pablo, Tarlac City

CASE STUDY FORMAT

I. IntroductionII. Objectives

Nurse centeredIII. Nursing Process

A. Data Basea. Nursing health history A

1. Demographic data2. Chief complaint3. History of present illness4. Past medical history5. Family history6. Social and personal history7. Review of system

b. Nursing health history B1. General Description Of Client2. Health Perception-Health Management Pattern3. Nutritional-Metabolic Pattern4. Elimination Pattern 5. Activity-Exercise Pattern6. Sleep-Rest Pattern7. Cognitive-Perceptual Pattern8. Self-Perception – Self-Concept Pattern9. Role-Relationship Pattern10.Sexuality-Reproductive Pattern11.Coping-Stress Tolerance Pattern12.Value-Belief Pattern

c. Physical examinationd. Laboratory Findingse. Review of anatomy and physiologyf. Pathophysiology (highlight patient manifestation)

B. NCPC. Drug StudyD. Medical and Nursing ManagementE. METHOD

IV. Evaluationa. Narrative evaluation of the objectivesb. Patient condition upon discharge

V. RecommendationVI. References/Bibliography

CENTRAL LUZON DOCTORS’ HOSPITALEDUCATIONAL INSTITUTION

San Pablo, tarlac city

CASE STUDY FORMATI. Introduction

a. Introduction about patient/background

Age

Gender

Address

b. Significance/relevance to the concept

c. Background knowledge

Definition

Causative agent

Clinical manifestation

Mode of transmission

d. Current/target population

e. Risk factors/contributing factors

f. Prognosis and complications

II. Nurse centered

a. Objectives

NURSING HEALTH HISTORY A

Demographic data

Patient:Date: Ward: Bed:Age: Sex: C/S: Religion:Examiner:Informant:

I. Chief complaint

II. History of present illness

III. Past medical history (include dates and complications, if any)A. Pediatric and Adult Illness

Mumps Pertussis HPNMeasles Rheumatic Heart DiseaseChicken Pox Pneumonia HepatitisRubella Tuberculosis Others

B. Immunizations/Tests

BCG HEP B For PneumoniaDPT Measles OthersOPV For Flu

C. Hospitalizations

D. Injuries

E. Transfusions

F. Obstetrics/gynecologic History

G. Medications

H. Allergies

IV. Family history

AGE List:Parents, Spouse, Children

Health Status or Cause of

Death

Diseases Present in the FamilyL D

L = Living TB = Tuberculosis HPN = Hypertension OB = ObesityD = Deceased DM = Diabetes Mellitus CA = Cancer J = Jaundice

HD = Heart Disease MI = Mental Illness KD = Kidney Disease O = Others

V. Social And Personal History

Birthplace: Birthday:Education: Ethnic Background:

Age and Sexes of Children (if any):

Client’s position in the family:

ResidenceHome Environment:

OccupationNature of present occupation: (stresses, hazards, etc.)

Financial Support System:

Habits (tobacco/alcohol use, others):

Diet (meal distribution, others)

Physical Activity/Exercise, if any:

Brief Description of Average Day:

VI. Review of system

General Description:Weight Loss: __________ Fatigue: ____________ Anorexia: ____________

Night Sweats: ____________ Weakness: __________

Skin:Itch: _________________________ Bruising: ________________________Rash: ________________________ Bleeding: ________________________Lesions: ______________________ Color Change: ____________________

Eyes:Pain Itch Vision LossDiplopia Blurring Excessive TearingGlasses/Contact Lenses

Ears:Earaches Discharge Tinnitus Hearing Loss

Nose: Obstruction Epistaxis Discharges

Throat and Mouth:Sore Throats Bleeding Gums Tooth Aches Decay

Neck:Swelling Dysphagia Hoarseness

Chest:Cough Sputum: (Amount & Character) HemoptysisWheeze Pain on Respiration Dyspnea: Rest/ExertionBreast: Lumps Pain Bleeding Discharge

CVS:Chest pain Palpitation Dyspnea on exertion EdemaPND Orthopnea Others: _________________________

GIT:Food tolerance Heartburn Nausea JaundiceVomiting Pain Bloating Excessive GasConstipation Change in BM Melena

GU:Dysuria Nocturia Retention Polyuria DribblingHematuria Flank painMale: Penile Discharge Lesion Testicular pains others:Female: Menarche: (age) LMP: (date) Cycle: _____ others:

Extremities:Joint pains varicose veins ClaudicationEdema Stiffness Deformities

Neuro:Headaches Dizziness Memory Loss FaintingNumbnessTingling Paralysis: ____________ Paresis: _________Seizures Others: ______________________________

Mental Health Status:Anxiety Depression InsomniaSexual Problems Fears

NURSING HEALTH HISTORY B

a. General Description Of Client

b. Health Perception-Health Management Pattern

c. Nutritional-Metabolic Pattern

d. Elimination Pattern

e. Activity-Exercise Pattern

f. Sleep-Rest Pattern

g. Cognitive-Perceptual Pattern

h. Self-Perception – Self-Concept Pattern

i. Role-Relationship Pattern

j. Sexuality-Reproductive Pattern

k. Coping-Stress Tolerance Pattern

l. Value-Belief Pattern

PHYSICAL EXAMINATION

GENERAL SURVEY:

Height: ______ Weight: ______ Body Makeup: ______ Communication Pattern: ______

Skin: Color: __________ Turgor: ___________ Bruises: __________

State of Hydration: _____________

Eyes: Sclera: _____________________ Pupils: ______________________

Respiratory: Easy Breathing in Distress No Distress

VITAL SIGNS:

HR ___________ / min Temperature: ____________

BP Supine R/L arm ___________ mmHg Capillary Refill: ____________

Sitting R/L arm ___________ mmHg RR: _____________________

Standing R/L arm ___________ mmHg

Others: ______________________________

BODY POSITION/ALIGNMENT:

Supine: _______ Fowlers: ________Semi-Fowlers: _______ others: _________________

Alignment: Appropriate Inappropriate

MENTAL ACUITY:

Oriented coherent appropriately responsive others: ___________

Disoriented incoherent inappropriately responsive

SENSORY/MOTOR RESTRICTIONS:

Amputation deformity paresis paralysis fracture

Gait hearing disorder speech others: ______________________

EMOTIONAL STATUS:

Euphoric Depressed Apprehensive

Angry/Hostile Others: ___________________________

MEDICALLY IMPOSED RESTRICTIONS:

CBR w/out BRP_____ BR w/ BRP_____ OOB – Chair_____ Restricted Ambulation _____

OTHER HEALTH RELATED PATTERNS:

Fatigue Restlessness Weakness Insomnia Coughing

Dyspnea Dizziness Pain Others: ______________________

ENVIRONMENT:

Room Temperature: Adequate Inadequate

Lighting: Adequate Inadequate

SAFETY:

Violations of medical asepsis: ________________________________________________

Violations of safety measures: ________________________________________________

ACTIVITIES OF DAILY LIVING:

Can/Cannot perform

Feeding Brushing teeth Bathing Transferring

Dressing Combing Others: __________________________________

PHYSICAL EXAMINATION FINDINGS

HEAD/SKULL:

EYES/VISION:

EARS/HEARING:

NOSE, MOUTH AND THROAT:

NECK AND LYMPH NODES:

THORAX (CHEST AND LUNGS):Anterior:

Posterior:

HEART AND CARDIOVASCULAR SYSTEM:

ABDOMEN:

NEUROLOGICAL:

MUSCULOSKELETAL:

GENITALIA:

EXTREMETIES:

(Follow IPPA format when documenting Physical Examination findings)

LIST OF IDENTIFIED NURSING PROBLEMS

PRIORITIZATION OF NURSING PROBLEM

1. Oxygenation2. Nutrition3. Elimination4. Activity and Exercise5. Comfort and Safety6. Sexual- Reproductive7. Psychological8. Psychosocial

LABORATORY FINDINGS

Review of anatomy and physiology

Pathophysiology (highlight patient manifestation)

NCP

ASSESSMENT INTERVENTIONEVALUATION

CUES NURSINGDIAGNOSIS

SCIENTIFICEXPLANATION

PROBLEM STATEMENT

(GOAL)

NURSINGINTERVENTION RATIONALE

Drug Study

DRUG NAME/

GENERIC

CLASSI-FICATION

DOSAGE/STOCKDOSE

ACTION INDICATION CONTRAINDICATION

SIDEEFFECTS

ARVERSEREACTION

NURSING RESPONSIBILITIES

Medical Management (

Nursing Management

Discharge Planning

METHOD (Example)

M (Medications):Lasix (Furosemide). Decreases swelling and blood pressure by increasing the amount of urine. Expect increased frequency and volume of urine. Report irregular heartbeat, changes in muscle strength, tremor, and muscle cramps, change in mental status, fullness, ringing/roaring in ears. Eat foods high in potassium such as whole grains (cereals), legumes, meat, bananas, apricots, orange juice, potatoes, and raisins. Avoid sun/sunlamps. Take with breakfast to avoid GI upset.Digoxin (Lanoxin). Used to treat CHF. Taking too much can result in GI disturbances, changes in mental status and vision. Report the following signs/ symptoms to your doctor: Nausea, vomiting, lack of appetite, fatigue, headache, depression, weakness, drowsiness, confusion, nightmares, facial pain, personality changes, sensitivity to light, light flashes, halos around bright objects, yellow or green color perception. Take pulse rate for one minute before dose and call doctor if pulse is below 60 before taking medication. Don’t increase or skip doses. Don’t take over the counter medications without talking to MD. Report for follow-up visits with your doctor to monitor lab values.

E (Exercise/Environment):Your eldest daughter will provide help with activities of daily living in the home. She will transport you to followup appointments. It is important to take steps to prevent falls: use of a 3-point cane for stability with ambulation; removing objects like throw rugs, cords that may cause fall; pausing before standing and again before walking to prevent drop in blood pressure. The “life line” allow you to access 911 for emergency help. You may resume activities as tolerated and you have a follow-up appointment with the doctor in 1 week.

T (Treatments):Apply A & D ointment to reddened coccyx and heels three times a day. Keep pressure off of these areas by keeping off of back and elevating heels off of bed. Keep skin clean and dry. Report any changes in skin condition to doctor. (i.e. open areas, drainage, elevated temp.)

H (Health knowledge of disease):Lasix can cause a loss of potassium. It is important to eat foods high in potassium and to have regular blood levels drawn to make sure potassium level stays normal. Monitoring the pulse rate before taking digoxin is important because this medicine can cause the pulse to drop. Call the doctor if pulse rate is below 60 beats per minute. New signs and symptoms should be reported to the physician, because they may indicate electrolyte imbalance &/or digoxin toxicity. Sodium causes water retention so it is important to limit sodium intake by eating a no added salt diet. Be careful to check labels for hidden salt content.

O (Outpatient/inpatient referrals): (include resources such as websites and organizations): American Heart Association www.americanheart.org Visiting Nurses’ Association for F/U skin assessment. Referral made to outpatient dietician for diet planning. Meals on Wheels.

D: (Diet):Do not add salt to your diet. Eat foods high in potassium such as bananas. We will arrange for you to meet with the dietician.

Evaluationa. Narrative evaluation of the objectivesb. Patient status after discharge

Recommendation

References/Bibliography